DON’T GET BENCHED!Prince George’s County Public Schools is collaborating with

Elaine Ellis Center of Health to make sure your athlete is ready to hit the groundrunning for school year 2019/2020.

• All students can receive a sports physical at their respective school, for just $25.

• For more details, please speak with your school’s athletic director or coach.

Visit your conveniently located Elaine Ellis Center of Health for all your family healthcare needs TODAY!

Elaine Ellis Center of Health 10001 Rhode Island Ave. College Park, MD 20740 (301)441-1605

Elaine Ellis Center of Health 1627 Kenilworth Ave. NE Washington,D.C. 20019 (202)803-2340

Go to www.eechealth.com and click on "Don't Get Benched Initiative" to complete consent forms and payment.

This program is supported by the health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS)

Prince Georges County Public Schools & Elaine Center of Health

“Don’t Get Benched” Sports Physical Initiative!

Elaine Ellis Center of Health (EECH) is a Not-for-Profit, Federally Qualified

Health Center (FQHC) dedicated to providing affordable, comprehensive,

preventive & primary healthcare services to individuals in the communities we

serve. As a FQHC, we are committed to offering said services in a clean, safe

environment, appropriate for meeting the healthcare needs of our target population.

In collaborating with PGCPS, EECH intends to utilize its licensed medical

Providers to offer convenient sports physicals for student athletes enrolled in the

county. Said sports physicals will be conducted onsite at PGCPS’s – thus

eliminating the extra burden of parents/guardians needing to take their child to a

medical Provider’s office. All equipment, materials, and or supplies needed for

this service will be rendered by EECH, at its sole expense.

The cost of the sports physical is twenty-five dollars ($25.00), and is paid online at

EECH’s website: www.eechealth.com

In addition to the functionality to make payments online, the required patient forms

are also on the website, and should be executed prior to the student athlete

receiving service.

10001 Rhode Island Ave College Park, MD 20740 Corporate (202) 803-2340

Prince George's County Public School "DON'T GET BENCHED" Sports Physical Initiative

Dear Parents/Guardians,

Elaine Ellis Center of Health (EECH) is providing Sports Physicals at your child’s school. If

you wish for your child to participate, please legibly complete the following information. Please

also attach a copy of your picture identification card to further support your consent.

Child’s Name: _______________________________________________________________________

Date of Birth: _______________________________ Age: _______ Sex: ____ M ____ F

Address: __________________________ City: ____________ State: ______ Zip Code: ____________

Phone Number: _____________ Email Address: __________________________________________

Do we have your permission to call you? Yes __No __ Text you? Yes __No __ Email you? Yes __ No __

What school does your child attend? ____________________________________________

Grade______

Additional Information

Who is your child’s Primary Care Physician? ____________________________________________

Is your child on any medication(s)? Yes __ No __ Name of medication? ________________________

Does your child have allergies to any medication(s)? Yes __ No __ Reaction: _____________________

Has your child had any past medical problems? Yes __ No __ or Surgery? Yes __ No __

If yes, please explain:

__________________________________________________________________________________

Does your child have a Dentist? Yes __ No __ If so, when was your child last seen? ________________

Does your child participate in any sports? Yes __ No __ Name of Sport: ________________________

Insurance: Health Insurance: ___________________________ Policy Number_____________________________Policy Holder: _____________________________ My child does not have health insurance ________

I am the legal parent/guardian of the above named child and I give my consent for EECH to give my

child a sports physical at school.

Further, if applicable, I give permission for EECH to mail referrals and/or prescriptions to the address

provided above.

Print Parent/Guardian Name: ________________________________________________________

Parent/Guardian Signature: _________________________________ Date: ___________________

updated February 2019

Parental Consent Form______________________________________

Prince George’s County Public Schools

Parental Permission for Participation in Interscholastic Athletics

Please fill in the appropriate blanks and return this form to the head coach of the sport in which you wish your son/daughter to participate. Permission to participate is not granted unless this form is signed by the parent or legal guardian. Permission applies only to the sport specified. A new form shall be submitted if guardianship or insurance information changes.

My child, ___________________________________, has my permission to participate in the First Name Last Name

following Prince George’s County athletic program for the __________________________ school year.

School _________________________ Sport _____________________________

_____________________ __/__/____ ___________________________________ Parents/Guardian Signatures (Date) Address

_______________________________ ___________________________________ Home Phone Work Phone

Request for Student Pre-Participation Physical Evaluation Form

It is extremely important that the school maintain a copy of your child’s pre-participation evaluation form in the individual school record kept in the school health nurse’s suite. Pre-participation forms are to be collected by the athletic director. The forms shall be kept in a secure file at all times.

Please sign and date if you agree to have your child’s physical evaluation form on file.

____________________________________ _______/______/_______ Parent or Guardian Signature (Date)

Insurance Information

The school does not provide insurance coverage for athletes other than the group catastrophic policy for county football programs. All participants shall have their own insurance coverage in effect prior to participation to cover injuries that might arise.

My child has injury insurance coverage under policy #______________________

through ________________________________________________________________. Insurance Company

______________________________ ______/_____/_____ Parent or Guardian Signature (Date)

In case of an emergency in which your child needs immediate medical treatment, we will send him/her to the nearest hospital and notify you immediately. The phone numbers you supply are of the utmost importance and should be updated when a change occurs. Please list your doctor’s name and phone number so that he may be contacted if necessary:

Name of Doctor _____________________________ Phone Number(s) ____________________________

PGIN 7540-2205 A

■ EVALUACIÓN FÍSICA PREVIA A LA PARTICIPACIÓN

FORMULARIO DE HISTORIAL CLÍNICONota: Complete y firme este formulario (con la supervisión de sus padres si es menor de 18 años) antes de acudir a su cita.Nombre: ________________________________________________________ Fecha de nacimiento: _____________________________Fecha del examen médico: _______________________________________ Deporte(s): ________________________________________Sexo que se le asignó al nacer (F, M o intersexual): _______________ ¿Con cuál género se identifica? (F, M u otro): _______________

Mencione los padecimientos médicos pasados y actuales que haya tenido. _______________________________________________________________________________________________________________________________________________________________¿Alguna vez se le practicó una cirugía? Si la respuesta es afirmativa, haga una lista de todas sus cirugías previas. ______________________________________________________________________________________________________________________________________________________________________________________________________________________Medicamentos y suplementos: Enumere todos los medicamentos recetados, medicamentos de venta libre y suplementos (herbolarios y nutricionales) que consume. _____________________________________________________________________________________________________________________________________________________________________________________________________¿Sufre de algún tipo de alergia? Si la respuesta es afirmativa, haga una lista de todas sus alergias (por ejemplo, a algún medica-mento, al polen, a los alimentos, a las picaduras de insectos).______________________________________________________________________________________________________________________________________________________________________________________________________________________________

Cuestionario sobre la salud del paciente versión 4 (PHQ-4)Durante las últimas dos semanas, ¿con qué frecuencia experimentó alguno de los siguientes problemas de salud? (Encierre en un círculo la respuesta)

Más de la Casi todosNingún día Varios días mitad de los días los días

Se siente nervioso, ansioso o inquieto 0 1 2 3No es capaz de detener o controlar la preocupación 0 1 2 3Siente poco interés o satisfacción por hacer cosas 0 1 2 3Se siente triste, deprimido o desesperado 0 1 2 3

(Una suma ≥3 se considera positiva en cualquiera de las subescalas, [preguntas 1 y 2 o preguntas 3 y 4] a fin de obtener un diagnóstico).

PREGUNTAS GENERALES (Dé una explicación para las preguntas en las que contestó “Sí”, en la parte final de este formulario. Encierre en un círculo las preguntas si no sabe la respuesta). Sí No

1. ¿Tiene alguna preocupación que le gustaríadiscutir con su proveedor de servicios médicos?

2. ¿Alguna vez un proveedor de servicios médicosle prohibió o restringió practicar deportes poralgún motivo?

3. ¿Padece algún problema médico o enfermedadreciente?

PREGUNTAS SOBRE SU SALUD CARDIOVASCULAR Sí No

4. ¿Alguna vez se desmayó o estuvo a punto dedesmayarse mientras hacía, o después de hacer,ejercicio?

PREGUNTAS SOBRE SU SALUD CARDIOVASCULAR (CONTINUACIÓN ) Sí No

5. ¿Alguna vez sintió molestias, dolor, compresióno presión en el pecho mientras hacía ejercicio?

6. ¿Alguna vez sintió que su corazón se aceleraba,palpitaba en su pecho o latía intermitente-mente (con latidos irregulares) mientras hacíaejercicio?

7. ¿Alguna vez un médico le dijo que tiene prob-lemas cardíacos?

8. ¿Alguna vez un médico le pidió que se hicieraun examen del corazón? Por ejemplo, electro-cardiografía (ECG) o ecocardiografía.

9. Cuando hace ejercicio, ¿se siente mareado osiente que le falta el aire más que a sus amigos?

10. ¿Alguna vez tuvo convulsiones?

12_Forms_215-226.indd 219 3/20/19 4:18 PM

PREGUNTAS SOBRE LA SALUD CARDIOVASCULAR DE SU FAMILIA Sí No

11. ¿Alguno de los miembros de su familia o pari-ente murió debido a problemas cardíacos o tuvouna muerte súbita e inesperada o inexplicableantes de los 35 años de edad (incluyendomuerte por ahogamiento o un accidente auto-movilístico inexplicables)?

12. ¿Alguno de los miembros de su familia padeceun problema cardíaco genético como la mio-cardiopatía hipertrófica (HCM), el síndrome deMarfan, la miocardiopatía arritmogénica delventrículo derecho (ARVC), el síndrome del QTlargo (LQTS), el síndrome del QT corto (SQTS),el síndrome de Brugada o la taquicardia ven-tricular polimórfica catecolaminérgica (CPVT)?

13. ¿Alguno de los miembros de su familia utilizóun marcapasos o se le implantó un desfibriladorantes de los 35 años?

PREGUNTAS SOBRE LOS HUESOS Y LAS ARTICULACIONES Sí No

14. ¿Alguna vez sufrió una fractura por estrés o unalesión en un hueso, músculo, ligamento, articu-lación o tendón que le hizo faltar a una prácticao juego?

15. ¿Sufre alguna lesión ósea, muscular, de losligamentos o de las articulaciones que le causamolestia?

PREGUNTAS SOBRE CONDICIONES MÉDICAS Sí No

16. ¿Tose, sibila o experimenta alguna dificultadpara respirar durante o después de hacerejercicio?

17. ¿Le falta un riñón, un ojo, un testículo (en elcaso de los hombres), el bazo o cualquier otroórgano?

18. ¿Sufre dolor en la ingle o en los testículos, otiene alguna protuberancia o hernia dolorosa enla zona inguinal?

19. ¿Padece erupciones cutáneas recurrentes o queaparecen y desaparecen, incluyendo el herpes oStaphylococcus aureus resistente a la meticilina(MRSA)?

PREGUNTAS SOBRE CONDICIONES MÉDICAS (CONTINUACIÓN ) Sí No

20. ¿Alguna vez sufrió un traumatismo craneoence-fálico o una lesión en la cabeza que le causóconfusión, un dolor de cabeza prolongado oproblemas de memoria?

21. ¿Alguna vez sintió adormecimiento, hormigueo,debilidad en los brazos o piernas, o fue incapazde mover los brazos o las piernas después desufrir un golpe o una caída?

22. ¿Alguna vez se enfermó al realizar ejerciciocuando hacía calor?

23. ¿Usted o algún miembro de su familia tiene elrasgo drepanocítico o padece una enfermedaddrepanocítica?

24. ¿Alguna vez tuvo o tiene algún problema consus ojos o su visión?

25. ¿Le preocupa su peso?

26. ¿Está tratando de bajar o subir de peso, oalguien le recomendó que baje o suba de peso?

27. ¿Sigue alguna dieta especial o evita ciertos tiposo grupos de alimentos?

28. ¿Alguna vez sufrió un desorden alimenticio?

ÚNICAMENTE MUJERES Sí No

29. ¿Ha tenido al menos un periodo menstrual?

30. ¿A los cuántos años tuvo su primer periodomenstrual?

31. ¿Cuándo fue su periodo menstrual más reciente?

32. ¿Cuántos periodos menstruales ha tenido en losúltimos 12 meses?

Proporcione una explicación aquí para las preguntas en las que contestó “Sí”.__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Por la presente declaro que, según mis conocimientos, mis respuestas a las preguntas de este formulario están completas y son correctas.Firma del atleta: _______________________________________________________________________________________________________Firma del padre o tutor: _________________________________________________________________________________________________Fecha: _________________________________________________________

© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Se concede permiso para reimprimir este formulario para fines educativos no comerciales, siempre que se otorgue reconocimiento a los autores.

12_Forms_215-226.indd 220 3/20/19 4:18 PM

■ PREPARTICIPATION PHYSICAL EVALUATION

PHYSICAL EXAMINATION FORMName: _________________________________________________________________ Date of birth: ____________________________

PHYSICIAN REMINDERS1. Consider additional questions on more-sensitive issues.

• Do you feel stressed out or under a lot of pressure?• Do you ever feel sad, hopeless, depressed, or anxious?• Do you feel safe at your home or residence?• Have you ever tried cigarettes, e-cigarettes, chewing tobacco, snuff, or dip?• During the past 30 days, did you use chewing tobacco, snuff, or dip?• Do you drink alcohol or use any other drugs?• Have you ever taken anabolic steroids or used any other performance-enhancing supplement?• Have you ever taken any supplements to help you gain or lose weight or improve your performance?• Do you wear a seat belt, use a helmet, and use condoms?

2. Consider reviewing questions on cardiovascular symptoms (Q4–Q13 of History Form).

EXAMINATIONHeight: Weight:

BP: / ( / ) Pulse: Vision: R 20/ L 20/ Corrected: □ Y □ N

MEDICAL NORMAL ABNORMAL FINDINGSAppearance• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, hyperlaxity,

myopia, mitral valve prolapse [MVP], and aortic insufficiency)

Eyes, ears, nose, and throat• Pupils equal• Hearing

Lymph nodes

Hearta

• Murmurs (auscultation standing, auscultation supine, and ± Valsalva maneuver)

Lungs

Abdomen

Skin• Herpes simplex virus (HSV), lesions suggestive of methicillin-resistant Staphylococcus aureus (MRSA), or

tinea corporis

Neurological

MUSCULOSKELETAL NORMAL ABNORMAL FINDINGSNeck

Back

Shoulder and arm

Elbow and forearm

Wrist, hand, and fingers

Hip and thigh

Knee

Leg and ankle

Foot and toes

Functional• Double-leg squat test, single-leg squat test, and box drop or step drop test

a Consider electrocardiography (ECG), echocardiography, referral to a cardiologist for abnormal cardiac history or examination findings, or a combi-nation of those.Name of health care professional (print or type): ___________________________________________________ Date: ___________________Address: ________________________________________________________________________ Phone: ___________________________Signature of health care professional: _____________________________________________________________________, MD, DO, NP, or PA

© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa-tional purposes with acknowledgment.

12_Forms_215-226.indd 221 3/20/19 4:18 PM

■ PREPARTICIPATION PHYSICAL EVALUATION

ATHLETES WITH DISABILITIES FORM: SUPPLEMENT TO THE ATHLETE HISTORYName: _________________________________________________________________ Date of birth: ____________________________

1. Type of disability:2. Date of disability:3. Classification (if available):4. Cause of disability (birth, disease, injury, or other):5. List the sports you are playing:

Yes No6. Do you regularly use a brace, an assistive device, or a prosthetic device for daily activities?7. Do you use any special brace or assistive device for sports?8. Do you have any rashes, pressure sores, or other skin problems?9. Do you have a hearing loss? Do you use a hearing aid?

10. Do you have a visual impairment?11. Do you use any special devices for bowel or bladder function?12. Do you have burning or discomfort when urinating?13. Have you had autonomic dysreflexia?14. Have you ever been diagnosed as having a heat-related (hyperthermia) or cold-related (hypothermia) illness?15. Do you have muscle spasticity?16. Do you have frequent seizures that cannot be controlled by medication?

Explain “Yes” answers here.___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please indicate whether you have ever had any of the following conditions:

Yes NoAtlantoaxial instability

Radiographic (x-ray) evaluation for atlantoaxial instabilityDislocated joints (more than one)Easy bleedingEnlarged spleenHepatitisOsteopenia or osteoporosisDifficulty controlling bowelDifficulty controlling bladderNumbness or tingling in arms or handsNumbness or tingling in legs or feetWeakness in arms or handsWeakness in legs or feetRecent change in coordinationRecent change in ability to walkSpina bifidaLatex allergy

Explain “Yes” answers here.___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct.Signature of athlete: ______________________________________________________________________________________________________Signature of parent or guardian: ______________________________________________________________________________________________Date: _________________________________________________________

© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.

12_Forms_215-226.indd 223 3/20/19 4:18 PM

■ PREPARTICIPATION PHYSICAL EVALUATION

MEDICAL ELIGIBILITY FORMName: _______________________________________________________ Date of birth: _________________________

□ Medically eligible for all sports without restriction

□ Medically eligible for all sports without restriction with recommendations for further evaluation or treatment of

__________________________________________________________________________________________________

__________________________________________________________________________________________________

□ Medically eligible for certain sports

__________________________________________________________________________________________________

__________________________________________________________________________________________________

□ Not medically eligible pending further evaluation

□ Not medically eligible for any sports

Recommendations: ___________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

I have examined the student named on this form and completed the preparticipation physical evaluation. The athlete does not have apparent clinical contraindications to practice and can participate in the sport(s) as outlined on this form. A copy of the physical examination findings are on record in my office and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the medical eligibility until the problem is resolved and the potential consequences are completely explained to the athlete (and parents or guardians).

Name of health care professional (print or type): __________________________________________ Date: ____________________________

Address: _________________________________________________________________________ Phone: ___________________________

Signature of health care professional: _____________________________________________________________________, MD, DO, NP, or PA

SHARED EMERGENCY INFORMATION

Allergies: ____________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Medications: ________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Other information: ____________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Emergency contacts: ___________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa-tional purposes with acknowledgment.

12_Forms_215-226.indd 225 3/20/19 4:18 PM

■ PREPARTICIPATION PHYSICAL EVALUATION

PHYSICAL EXAMINATION FORMName: _________________________________________________________________ Date of birth: ____________________________

PHYSICIAN REMINDERS1. Consider additional questions on more-sensitive issues.

• Do you feel stressed out or under a lot of pressure?• Do you ever feel sad, hopeless, depressed, or anxious?• Do you feel safe at your home or residence?• Have you ever tried cigarettes, e-cigarettes, chewing tobacco, snuff, or dip?• During the past 30 days, did you use chewing tobacco, snuff, or dip?• Do you drink alcohol or use any other drugs?• Have you ever taken anabolic steroids or used any other performance-enhancing supplement?• Have you ever taken any supplements to help you gain or lose weight or improve your performance?• Do you wear a seat belt, use a helmet, and use condoms?

2. Consider reviewing questions on cardiovascular symptoms (Q4–Q13 of History Form).

EXAMINATIONHeight: Weight:

BP: / ( / ) Pulse: Vision: R 20/ L 20/ Corrected: □ Y □ N

MEDICAL NORMAL ABNORMAL FINDINGSAppearance• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, hyperlaxity,

myopia, mitral valve prolapse [MVP], and aortic insufficiency)

Eyes, ears, nose, and throat• Pupils equal• Hearing

Lymph nodes

Hearta

• Murmurs (auscultation standing, auscultation supine, and ± Valsalva maneuver)

Lungs

Abdomen

Skin• Herpes simplex virus (HSV), lesions suggestive of methicillin-resistant Staphylococcus aureus (MRSA), or

tinea corporis

Neurological

MUSCULOSKELETAL NORMAL ABNORMAL FINDINGSNeck

Back

Shoulder and arm

Elbow and forearm

Wrist, hand, and fingers

Hip and thigh

Knee

Leg and ankle

Foot and toes

Functional• Double-leg squat test, single-leg squat test, and box drop or step drop test

a Consider electrocardiography (ECG), echocardiography, referral to a cardiologist for abnormal cardiac history or examination findings, or a combi-nation of those.Name of health care professional (print or type): ___________________________________________________ Date: ___________________Address: ________________________________________________________________________ Phone: ___________________________Signature of health care professional: _____________________________________________________________________, MD, DO, NP, or PA

© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa-tional purposes with acknowledgment.

12_Forms_215-226.indd 221 3/20/19 4:18 PM

■ PREPARTICIPATION PHYSICAL EVALUATION

ATHLETES WITH DISABILITIES FORM: SUPPLEMENT TO THE ATHLETE HISTORYName: _________________________________________________________________ Date of birth: ____________________________

1. Type of disability:2. Date of disability:3. Classification (if available):4. Cause of disability (birth, disease, injury, or other):5. List the sports you are playing:

Yes No6. Do you regularly use a brace, an assistive device, or a prosthetic device for daily activities?7. Do you use any special brace or assistive device for sports?8. Do you have any rashes, pressure sores, or other skin problems?9. Do you have a hearing loss? Do you use a hearing aid?

10. Do you have a visual impairment?11. Do you use any special devices for bowel or bladder function?12. Do you have burning or discomfort when urinating?13. Have you had autonomic dysreflexia?14. Have you ever been diagnosed as having a heat-related (hyperthermia) or cold-related (hypothermia) illness?15. Do you have muscle spasticity?16. Do you have frequent seizures that cannot be controlled by medication?

Explain “Yes” answers here.___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please indicate whether you have ever had any of the following conditions:

Yes NoAtlantoaxial instability

Radiographic (x-ray) evaluation for atlantoaxial instabilityDislocated joints (more than one)Easy bleedingEnlarged spleenHepatitisOsteopenia or osteoporosisDifficulty controlling bowelDifficulty controlling bladderNumbness or tingling in arms or handsNumbness or tingling in legs or feetWeakness in arms or handsWeakness in legs or feetRecent change in coordinationRecent change in ability to walkSpina bifidaLatex allergy

Explain “Yes” answers here.___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct.Signature of athlete: ______________________________________________________________________________________________________Signature of parent or guardian: ______________________________________________________________________________________________Date: _________________________________________________________

© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.

12_Forms_215-226.indd 223 3/20/19 4:18 PM

■ PREPARTICIPATION PHYSICAL EVALUATION

MEDICAL ELIGIBILITY FORMName: _______________________________________________________ Date of birth: _________________________

□ Medically eligible for all sports without restriction

□ Medically eligible for all sports without restriction with recommendations for further evaluation or treatment of

__________________________________________________________________________________________________

__________________________________________________________________________________________________

□ Medically eligible for certain sports

__________________________________________________________________________________________________

__________________________________________________________________________________________________

□ Not medically eligible pending further evaluation

□ Not medically eligible for any sports

Recommendations: ___________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

I have examined the student named on this form and completed the preparticipation physical evaluation. The athlete does not have apparent clinical contraindications to practice and can participate in the sport(s) as outlined on this form. A copy of the physical examination findings are on record in my office and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the medical eligibility until the problem is resolved and the potential consequences are completely explained to the athlete (and parents or guardians).

Name of health care professional (print or type): __________________________________________ Date: ____________________________

Address: _________________________________________________________________________ Phone: ___________________________

Signature of health care professional: _____________________________________________________________________, MD, DO, NP, or PA

SHARED EMERGENCY INFORMATION

Allergies: ____________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Medications: ________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Other information: ____________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Emergency contacts: ___________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa-tional purposes with acknowledgment.

12_Forms_215-226.indd 225 3/20/19 4:18 PM